Valu Jet Flight #592 Crash Incident Analysis_Bazeley-Mineta Transportation Institute
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Transcript of Valu Jet Flight #592 Crash Incident Analysis_Bazeley-Mineta Transportation Institute
11/10/14 DesignStrategy-USA.com 1
ValuJet Flight 592 Transportation as the “cause”
“Improper Transportation of Hazardous Materials”
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ValuJet Flight 592: Aircraft: McDonnell Douglas DC-9-32
Manufactured 1967, 662 produced
2006, 294 DC-9-30 remain in service
2 Pratt & Whitney JT8D-9A Engines
14,500 lbs thrust
115 Passengers
Cruising Speed 570 mph
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ValuJet Flight 592: The Incident 5/11/1996
May 11, 1996 at 2:14 EST ValuJet Flight 592 crashed Into the Florida Everglades about 10 Minutes after take-off from Miami Intl. Airport
Cause: In-flight Fire and Impact with Terrain
110 passengers/crew Died on impact
In-flight fire attributed to the Improper handling and transportation of hazardous materials by ValuJet’s maintenance contractor SabreTech
Passenger Oxygen Generators Human Error Factor/FAA Procedures
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ValuJet 592: Location of The Crash SiteFlorida Everglades – 12 Miles Northwest of Miami International Airport
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ValuJet Flight 592: Hazardous Materials Involvement
FRD CARGO HOLD – Fire Origin
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ValuJet Flight 592: Hazardous Materials Involvement
Passenger Oxygen Generator/Mask
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ValuJet Flight 592: In-Flight Activity before Impact
Preceding the plane’s impact the CVR recorded the captain stating “fire” and the first officer replying, “uh smoke in the cockpit…smoke in the cabin’.
1411:12, the CVR recorded a flight attendant shouting, “completely on fire.”
1411:26, the north departure controller advised the Miami Center that flight 592 was returning with an emergency.
1411:37, the first officer transmitted that they needed the closest airport.
1411:41, the controller replied,” Critter five ninety two they’re gonna be … standing by for you, you can plan runway one two when able to direct to Dolphin (an electronic navigational aid) now.”
1411:46, the first officer responded that the flight needed radar vectors.
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ValuJet 592: In-Flight Activity before Impact
1411:49, the controller instructed flight 592 to turn left heading one four zero, and was acknowledged by the first officer.
1412:45, the controller transmitted, “Critter five ninety two keep the turn around heading uh one two zero.” No response from the flight crew.
The last recorded FDR data showed the aircraft at 7,200 feet MSL, at a speed of 260 KIAS, and on the heading 218 degrees.
1412.48, the FDR stopped recording data, while the planes transponder continued to function recorded by ATC.
The impact occurred at 1413:42.
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The Crash Site: Point of ImpactFlorida Everglades – Deep Water Swamp – Bedrock Bottom
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Response: Resources
Airport Foam Apparatus
The Miami-Dade Department Airport Fire Rescue Division (MDFR)
Conduct physical search and rescue operations in damaged or collapsed structures and transportation accidents.
Provide EM care at disaster sites for trapped victims and Task Force members.
Carry out reconnaissance duties to assess damage and determine needs, use collected information to provide feedback to all agencies involved.
Provide disaster communications support using state-of-the-art satellite systems.
Conduct hazardous materials survey/evaluations of affected areas.
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Response: Recovery & Reconstruction
Collected Fragments Cargo Hold-Mock-up
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Response: The NTSB “Go Team”
ValuJet 952 Report
NTSB “Go Team” is a group of investigators; on-call for immediate accident scene assignment
The remoteness of a crash site does not diminish the need to establish NTSB jurisdiction
The Go Team establishes a meeting place/EOC at the nearest location to the crash site
The NTSB safety officer conducts an accident site risk assessment by coordinating with the local Incident Commander
The safety officer or on-scene commander conducted daily briefings
NTSB has the sole responsibility to determine the cause of the accident
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IMPACT: On Transportation
ValuJet CEO JORDAN
ValuJet was grounded by the FAA on June 16, 1996
ValuJet never recovered from the crash. In 1997, it merged with AirTran
Over 4,000 ValuJet employees lost jobs
July 1997, FAA indicated 14 ongoing investigation of oxygen generator transport on ailrines since the ValuJet crash , May 1, 1996
2001 FAA mandated fire suppression and detectors in all class D cargo holds
More restrictive technical and hazardous material proceedures and personel training implemented
Cockpit procdures for the use of oxygen masks and smoke goggles-revised FAA guidiance/specifications
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IMPACT: On Victims’ Families
ValuJet CEO JORDAN
SabreTech’s fines of $2 million and $9 million in restitution and 110 counts of manslaughter and 110 counts of third degree murder were eliminated by the U.S. 11th Circuit Court of Appeals in 2001.
Florida State prosecutors dropped the murder case against SabreTech, ValuJet’s defunct maintenance contractor, in exchange for a $500,000 donation to aviation causes.
The federal court judge re-sentenced SabreTech to 3 years probation and a $500,000 fine for one count of improperly handling hazardous materials.
The psychological impact upon the victims’ families of these light-weight rulings and penalties exacted on ValuJet and SabreTech remains devastating…
1999 Flight 952, Everglades Memorial dedicated
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ValuJet Flight 952: Lessons Learned
Failure of the FAA to adequately monitor ValuJet’s heavy maintenance programs and responsibilities, including ValuJet’s oversight of its contractors/ SabreTech’s repair certificate
Failure to insure that both ValuJet and contract maintenance facility employees were aware of the “no-carry” hazardous materials policy and had received appropriate hazardous materials.
U.S. passenger airlines are now required to have fire suppression and detection systems in specified cargo compartments; oxygen generators are banned as cargo on passenger aircraft
Federal Aviation Administration has hired more inspectors of hazardous materials and revamped its program of airline oversight
Frequent Training employees and contractors on the proper handling, packaging, labeling, and documentation of airline cargo and hazardous materials---FAA needs to be more proactive in implementing improvements generators are banned as cargo on passenger aircraft
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ValuJet Flight 952: Conclusion
There was a major breakdown in the human factors performance areas which include:
1.) ValuJet’s management oversight and training
2.) Contractor due diligence in the personnel training of hazardous material regulations and handling procedures
3.) FAA timely implementation of corrective standards and procedures, guidance, oversight and enforcement for commercial airlines transporting and handling hazardous/dangerous cargo materials.